Inside Health

Questions for Your Doctor

What to Ask About Peptic Ulcers

By INGFEI CHEN

Confronting a new diagnosis can be frightening — and because research changes so often, confusing. Here are some questions you may not think to ask your doctor, along with notes on why they’re important.

James O'Brien

Upper abdominal symptoms like burning or gnawing pain, discomfort, gas in the upper part of the stomach, bloating and nausea can be brought on by an ulcer. But these kinds of common symptoms, known as dyspepsia, more typically result from other problems, like acid reflux disease or poor stomach emptying.

The two most common causes are gastrointestinal damage from infection by an ulcer-inducing bacterium, or from taking painkillers known as nonsteroidal anti-inflammatory drugs, or Nsaids. A small percentage of patients have ulcers from other causes, like excess stomach acid secretion, which physicians treat with acid-suppressing medication long term.

How can you tell if I have an ulcer?

The only way to know for sure is to look inside the upper gastrointestinal (GI) tract with an endoscope, a flexible tube with a small camera at its end. In clinical practice guidelines, that exam is recommended if a patient is over 55 or has serious “alarm” symptoms like sudden weight loss, vomiting, GI bleeding or anemia, which may signal a bleeding ulcer.

But because endoscopy is invasive and expensive, and because only about 15 percent to 25 percent of people with dyspepsia actually have an ulcer, clinical guidelines advise skipping that exam in most cases. Instead, the doctor should test for a microbe that causes ulcers, and if it is present, treat the infection. If that approach does not solve the problem, then an endoscopy may be ordered.

How do you check whether I have the ulcer bug?

A blood test can detect antibodies against H. pylori, but falsely positive results may occur because the antibodies can linger for years after an infection is gone. So, any positive blood result should be confirmed with a more accurate assay, like the breath test or the stool antigen test (which requires a fresh stool sample). But those tests should be done only when a patient is not taking acid-suppressing medication, which can skew the results.

Depending on where you were born and raised, however, your doctor may decide to forgo H. pylori testing and just put you on acid-blocking medication for a month or two to see if that helps. That strategy makes sense if the prevalence of H. pylori infection in a population is low — less than about 20 percent — which is generally true of middle-class or affluent residents born in the United States. Recent immigrants from place with higher infection rates, like Asia, Eastern Europe and Mexico, are more likely to carry the bug.

What does treatment for the ulcer bug entail?

The standard regimen is triple therapy: the antibiotics amoxicillin and clarithromycin and a drug called a proton-pump inhibitor or P.P.I., which reduces production of stomach acid. Omeprazole (Prilosec), esomeprazole (Nexium) and lansoprazole (Prevacid) are P.P.I.’s. In its simplest form, triple therapy requires taking 6 pills a day, for 10 to 14 days.

Quadruple therapy consists of the antibiotics tetracycline and metronidazole, as well as bismuth (Pepto-Bismol) and a P.P.I. — as many as 15 to 20 pills a day.

What do I need to know about complying with the antibiotic therapy?

Finishing all your pills is crucial, experts say, because if you stop halfway through, you face a 40 percent to 50 percent chance that the bacteria will develop resistance to the drugs. To help avoid forgetting doses or losing track of what you have taken, buy a pillbox and put all your medicines for the day in it each morning. Or, get a pillbox with separate compartments for each day of the week.

What are the side effects of H. pylori therapy?

Ask your doctor, so you know what to expect. For instance, the antibiotics might cause abdominal cramping, diarrhea, nausea and vomiting. Clarithromycin sometimes results in a metallic taste in the mouth.

How effective are the drug cocktails?

The treatments can clear the infection in as many as 85 percent to 90 percent of patients who have never taken any of the antibiotics. But H. pylori can be resistant to clarithromycin in as many as 10 percent to 15 percent of people, and to metronidazole in 25 percent to 30 percent of people. Then, experts say, the eradication rate may drop to as low as about 50 percent.

To check whether therapy has worked, you should be tested for the ulcer bug afterward. Re-treatments with the same regimen can eliminate the infection in most patients. If you fail multiple rounds, your doctor may refer you to a gastroenterologist.

How do Nsaid pain relievers cause ulcers?

Nsaids, which include aspirin, ibuprofen and naproxen, foster formation of sores in the digestive tract — particularly the stomach — in two ways. The damage predominantly occurs through the bloodstream; once absorbed, the drugs inhibit the production of hormonelike substances called prostaglandins that normally protect the stomach lining, so it is left vulnerable to erosion from acid. Nsaids may also cause topical damage: if a pill sits on the mucous layer of the stomach for hours, it can cause a direct chemical burn that eats away at the gastrointestinal lining, which is partly why patients are advised to take their pills with food or liquids.

How much of an Nsaid is too much when it comes to the risk of getting an ulcer?

Nsaids raise the odds of developing an ulcer even when lower-dose over-the-counter forms are used. For example, low-dose aspirin doubles to quadruples the normal risk of gastrointestinal bleeding and ulcer problems. The more you take, the greater the hazard. And you may not even realize you have an Nsaid ulcer because most cases do not cause obvious symptoms; serious bleeding or perforation may strike with little warning.

But when does the increase in ulcer risk rise to a level that warrants serious concern? Nsaid users should be particularly worried about getting an ulcer if they fall under these categories:

¶ Older than 65.

¶ Had a previous ulcer or bleeding ulcer.

¶ Take high doses of Nsaids.

¶ On corticosteroids or blood-thinning drugs like warfarin.

¶ Use multiple types of Nsaids together, like aspirin and another Nsaid.

All are major risk factors for the development of ulcers in people taking Nsaids.

How can I protect myself from developing an ulcer?

If you are starting chronic Nsaid therapy for arthritis, or aspirin therapy for heart disease, talk to your physician about being tested and treated for H. pylori. That is important, because infection by the bug appears to increase the risk of Nsaid-related ulcers.

In addition, several protection strategies can also help lower your ulcer risk. These are some of the steps:

¶ Switch to other types of analgesics that do not cause ulcers, like acetaminophen or opioid painkillers.

¶ Use celecoxib, a selective type of Nsaid known as a COX-2 inhibitor, which is widely regarded to be safer for the GI tract than traditional Nsaids. (The Food and Drug Administration, however, has not approved that claim.)

¶ Take the lowest Nsaid dose possible for the least amount of time possible. You might try taking one pain pill a day instead or two, or using acetaminophen on alternate days.

¶ Take your Nsaid with a P.P.I. acid blocker to protect your stomach. In two drug company-sponsored clinical trials of arthritis patients on Nsaid treatment, researchers detected ulcers in only about 5 percent of those who also took Nexium, compared with 17 percent of those who did not.

I have heart disease. If I need to take an Nsaid, which one is safest for me?

Figuring out the answer can be complicated, because chronic use of Nsaids — the traditional kind as well as celecoxib — raises the risk of heart attack and stroke. At the same time, blood-thinning antiplatelet drugs like clopidogrel and warfarin can, like aspirin, help ward off a second heart attack, but they may also lead to ulceration and bleeding.

So to determine the best combination of medicines, your physician must balance your heart risks with the gastrointestinal risks, factoring in your medical history and any other drugs you take — as well as issues of cost and the ease of sticking to the pill schedule. The American College of Cardiology Foundation, American College of Gastroenterology, and the American Heart Association released an expert consensus report in late 2008 with recommendations for cardiologists on prescribing antiplatelet therapy and Nsaids in their patients.